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SUMMARY The effect of the use of a lip bumper with anterior vestibular shields on the maxilla
was studied in twenty-two 9–14-year-old children with a space deficiency in the maxillary
dental arch. The lip bumper was used for 1 year.
The effect of the treatment was evaluated from dental casts and profile cephalograms made
before and after treatment. Both the width of the maxillary dental arch at the premolars and
the length of the arch increased significantly by about 2 mm. The effect of the treatment on
the antero-posterior position of the first molars was small. In one subject the molar was
distalized 2.8 mm. The average effect was, however, a reduction in the anterior movement
of the molar within the face by about 0.5 mm, i.e. the maxilla moved anteriorly 1 mm, but
the molar only 0.4 mm. No skeletal effects were found when the group of subjects treated
with a lip bumper was compared with a reference sample of untreated individuals. The
main effects of a maxillary lip bumper thus seem to be a widening of the dental arch across
the premolars, a moderate increase in arch length due to eruption and slight proclination
of the incisors, and moderate distal tipping of the first molars.
Figure 2 Measuring points used in the recording of the dental arch dimensions. The figure also shows the median changes
in widths and arch length during the period of observation.
right and left first molars to the mid-point of the rod was inserted in the buccal tubes of the right
incisal edge of the two central incisors. The mean and left first permanent molar bands, respect-
of the measurement to the right and left incisor ively. The length of the straight metal rod, which
was used as the variable for arch length. All extended vertically gingivally and occlusally
measurements were made with electronic dial mesial to the mesial opening of the buccal tubes,
calipers to the next tenth of a millimetre. The was 15 mm. The metal rod was used to measure
results of the measurements of the dental arch the inclination of the first molars in relation to
dimensions were compared with the annual OLP. The design of the rod on the right and
changes of the same dimensions in the untreated left sides was different so that a differentiation
group of Moyers et al. (1976). For this comparison, could be made. In the cephalometric analysis the
their sample was matched with the present indi- change in position of point m, as well as in the
viduals with regard to sex and age. This matching inclination of the molar on the two sides was
was undertaken separately for each variable. averaged. The dimensions measured on the
The reference points and lines used in the cephalograms were reduced to zero magnifica-
cephalometric analysis are shown in Figure 3. tion. The changes of the distances ss–pm, pr–pm,
The point m was located on the distal surface of and is–pm, as well as of the angle ILs/NL in the
the first molar band. Before radiography a metal treated group were compared with the annual
changes of the same variables in the untreated
sample of Bahtia and Leighton (1993). Their
sample was matched with the present individuals
with regard to sex and age. This was carried
out individually for each variable. Analysis of
antero-posterior linear changes was performed
with the method of Pancherz (1982). A co-
ordinate system, consisting of the occlusal line
(OL) and a perpendicular to this line through
the point sella (OLP), was drawn on a tracing of
the pre-treatment cephalogram. The co-ordinate
system was transferred to the post-treatment
cephalogram by superimposing on structures of
the anterior cranial base as described by Björk
(1968). All variables recorded on the casts or
cephalograms were measured twice with new
markings on the casts or new tracings. The
Figure 3 Reference points and lines used in the measure- mean of the two measurements was used in the
ments on the cephalograms. analysis.
28 R . H Ä S L E R A N D B. I N G E RVA L L
Errors of the method and statistical of the results of the treatment was based on
methods used replicated measurements, the errors were reduced
by a factor of 0.7.
The errors of the method were calculated from
the duplicate measurements made before and
after treatment. Systematic differences between Results
the duplicate measurements were tested with
The changes of the dimensions of the maxillary
Wilcoxon’s matched pairs, signed ranks test. The
dental arch during treatment are given in Table 1.
accidental errors of the method (si) were calcu-
The variation in number of observations in Table 1
lated with the formula
and in Figure 4 is due to the fact that the widths
si = √Σd2/2n, at the premolars/deciduous molars and at the
canines could not be measured in all subjects
where d is the difference between two measure- due to the varying stage of development of the
ments and n the number of recordings. dentition. There was no difference in the changes
Differences between distributions were tested between cases having and not having had a TPA
with Mann–Whitney’s U-test and between paired during treatment. Therefore, no differentiation
observations with Wilcoxon’s matched pairs, with regard to the use of a TPA was made. The
signed ranks test. change in width between the first permanent
The number of duplicate determinations of the molars during the treatment varied widely from
variables measured on the casts varied between a decrease of 2 mm to an increase of 7.5 mm. The
18 and 44. No systematic differences were found median change during treatment was small and
for these variables. The accidental errors varied not significant, and nor was any significant
from 0.16 to 0.41 mm. The number of duplicate difference found in relation to the reference
determinations of the cephalometric variables sample. The widths between the second
was 36. One systematic difference was found. premolars or the second deciduous molars, as
The angle ILs/NL was, on average, 0.40 degrees well as between the first premolars, increased
larger at the second than at the first measure- significantly during treatment and developed
ment (0.01 < P < 0.05). The accidental errors for significantly differently to the corresponding
the measurement of distances on the cephalo- dimensions in the reference sample. The change
grams varied between 0.20 and 0.31 mm. The in width in the individual cases treated with the
errors for the measurement of the molar inclin- lip bumper is shown in Figure 4. All subjects of
ation and for the angle ILs/NL were 0.71 and the treatment group had an increase of the
0.81 degrees, respectively. Because the analysis dimensions mentioned. The widths between
Table 1 Median and range (in mm) of changes in the dimensions of the maxillary dental arch during
treatment. The table also gives the median annual changes in the matched reference sample (Moyers et al.,
1976). The varying number of observations is due to varying development of the dentition.
*0.01 < P < 0.05; **0.001 < P < 0.01; ***P < 0.001; NS, non-significant.
E F F E C T O F A M A X I L L A RY L I P BU M P E R 29
Table 2 Median and range (in mm and degrees) of changes in antero-posterior position of points ss, is, and
m, as well as dimensions of the maxilla and inclination of the maxillary central incisors and maxillary molars
during treatment. The table also gives the median annual changes in maxillary dimensions and in the
inclination of the incisors in the matched reference sample (Bahtia and Leighton, 1993) n = 18.
A positive sign means anterior movement or change in inclination in an anterior direction. NS, not significant.
**0.001 > P > 0.01.
significant. The number of inter-canine width distance ss–pm increased similarly in the treated
observations was, however, small. The increase in group and the reference sample. The same is true
maxillary inter-premolar widths achieved by the for the distances pr–pm and is–pm. In relation to
lip bumper treatment was much the same as the reference line OLP, the maxilla (point ss) in
the increase in mandibular inter-premolar the treated group moved 1 mm (median)
widths achieved by the use of a lower lip anteriorly during the period of observation.
bumper (Osborn et al., 1991; Nevant et al., 1991; Unfortunately, the literature contains no such
Werner et al., 1994; Grossen and Ingervall, 1995; measurement for untreated samples. The median
Davidovitch et al., 1997; O’Donnell et al., 1998). anterior movement of is was 1.5 mm, i.e.
In contrast to the situation in the mandible, somewhat more than for point ss. This may
there is possibly more than one explanation for be due to eruption of the incisor and/or to a
the increase in arch width from a lip bumper slight increase in its inclination, which changed
used in the maxilla. One explanation, which more in the treated group than in the reference
would hold true for both the maxilla and the sample. The anterior movement of the first molar
mandible, is that the lip bumper changes the oral (point m) was only half that of the maxilla (point
environment by holding the lips and cheeks ss) and signifies a slight holding effect (median
away from the dental arches, thus altering the about half a millimetre) from the lip bumper on
equilibrium between the forces from the cir- the molar. In single cases the molars may move
cumoral soft tissues and from the tongue acting distally but this rarely exceeds 1 mm. The small
on the teeth. The effect of the lip bumper would effect of the lip bumper on the molars in terms
then be similar to that of the vestibular shields of of holding or distalization may be due to the
a Fränkel appliance (Fränkel, 1974). The other small force produced by the upper lip but, as
explanation is that a maxillary lip bumper mentioned in the introduction, in many studies
increases the growth in the mid-palatal suture. a similar small effect was also found in the
This has been shown to be the case with the use mandible. In a previous study of the effect of a
of vestibular shields in growing rabbits (Kalogirou lip bumper in the mandible (Grossen and
et al., 1996). In that animal experiment, however, Ingervall, 1995), the state of development and
the shields were extended to create tension in eruption of the second molars was found not to
the buccinator insertions. The authors suggested influence the effect of the bumper on the first
that the increased sutural growth was due to molars. A similar analysis could not be carried
relief of the buccal pressure and continued out in the present study because we refrained
tongue pressure against the dento-alveolar bone, from taking additional radiograms, and because
leading to separation of the adjoining bone and one or both second molars were only erupted in
sutural growth as a passive filling process. In the four cases as judged from the dental casts.
present study, the increase in width between the The increase in arch length from molar holding/
first molars, as well as between the second pre- distalization and from incisor eruption/proclination
molars/second deciduous molars and between the was limited, and quite comparable with that found
first premolars/first deciduous molars, and be- with the use of a lip bumper in the mandible
tween the canines was the same in subjects with (Osborn et al., 1991; Grossen and Ingervall, 1995;
and without a TPA during treatment. A TPA Davidovitch et al., 1997; O’Donnell et al., 1998).
holds the two maxillary halves together, thereby The main effect of a maxillary lip bumper seems
decreasing the possibility of mid-palatal sutural to be a widening of the dental arch across the
growth expressing itself. Therefore, the explan- premolars. This is, of course, beneficial, but it is
ation for the increase in maxillary dental arch not the ultimate solution to the space deficiency
width produced by the lip bumper treatment is problem in a retrognathic maxilla. On the other
most likely the change in equilibrium of the hand, no negative effects of the use of a maxil-
forces acting on the surfaces of the teeth. lary lip bumper were found.
The growth in length of the maxilla was not It is an open question whether the expansive
affected by the lip bumper treatment as the effect of a lip bumper and the proclination of the
32 R . H Ä S L E R A N D B. I N G E RVA L L
incisors are stable in the long term. The results of Hodge J J, Nanda R S, Ghosh J, Smith D 1997 Forces pro-
Soo and Moore (1991) indicated an adaptation of duced by lip bumpers on mandibular molars. American
Journal of Orthodontics and Dentofacial Orthopedics
the lower lip to the tooth position achieved with
111: 613–622
lower lip bumper treatment. In their study, the
Houston W J B, Edler R 1990 Long-term stability of the
pressure from the lower lip both at rest and during
lower labial segment relative to the A–Pog line. Euro-
speech first increased (at 1 month), but then (at
pean Journal of Orthodontics 12: 302–310
8 months) decreased below baseline. These obser-
Ingervall B, Thüer U 1998 No effect of lip bumper therapy
vations are at variance with the results of recent on the pressure from the lower lip on the lower incisors.
studies. O’Donnell et al. (1998) found no decrease European Journal of Orthodontics 20: 525–534
of the pressure from a lower lip bumper on the Kalogirou K, Ahlgren J, Klinge B 1996 Effects of buccal
first molars after one year of uninterrupted use. shields on the maxillary dentoalveolar structures and the
Ingervall and Thüer (1998) found the pressure midpalatal suture—histologic and biometric studies in
from the lower lip on the lower incisors to be the rabbits. American Journal of Orthodontics and Dento-
same after 8 months of lower lip bumper treat- facial Orthopedics 109: 521–530
ment as at the start. The lip had not adapted to Moyers R E, van der Linden F, Riolo M, McNamara J Jr
the changed position of the incisors, nor had it 1976 Standards of human occlusal development, Mono-
reacted to the extension by the lip bumper. There- graph No 5, Craniofacial Growth Series. Center for Human
fore, the conclusion of Houston and Edler (1990) Growth and Development, University of Michigan, Ann
Arbor, Michigan
may be correct, namely, ‘with a few exceptions,
the initial position of the lower incisors provides Nevant C T, Buschang P H, Alexander R G, Steffen J M
1991 Lip bumper therapy for gaining arch length.
the best guide to their position of stability’.
American Journal of Orthodontics and Dentofacial
Orthopedics 100: 330–336
Address for correspondence O’Donnell S, Nanda R S, Ghosh J 1998 Perioral forces and
Professor Bengt Ingervall dental changes resulting from mandibular lip bumper
treatment. American Journal of Orthodontics and
Klinik für Kieferorthopädie
Dentofacial Orthopedics 113: 247–255
Freiburgstrasse 7
Osborn W S, Nanda R S, Currier G F 1991 Mandibular arch
CH-3010 Bern, Switzerland
perimeter changes with lip bumper treatment. American
Journal of Orthodontics and Dentofacial Orthopedics 99:
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